The Impact of Postoperative Stroke and Myocardial Infarction on One-Year Survival Following Carotid Revascularization
Ahmed Abdelkarim1, Mohammed Hamouda1, Mohamed Abdalla1
1Division of Vascular and Endovascular Surgery, Department of Surgery, UC San Diego (UCSD), San Diego, CA; Division of Vascular & Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), UC San Diego (UCSD), San Diego, CA.
Insights
Postoperative stroke or myocardial infarction (MI) significantly increases 1-year mortality after carotid revascularization. Transfemoral carotid artery stenting (TFCAS) showed higher mortality compared to carotid endarterectomy (CEA) and transcarotid artery revascularization (TCAR).
Area of Science:
- Vascular Surgery
- Cardiovascular Research
- Clinical Outcomes Analysis
Background:
- Postoperative stroke and myocardial infarction (MI) are major complications following carotid revascularization, significantly impacting patient morbidity and mortality.
- The choice of carotid revascularization technique may influence the risk and outcomes associated with these adverse events.
Purpose of the Study:
- To investigate the impact of in-hospital stroke or MI on 1-year survival rates across three carotid revascularization procedures: carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), and transcarotid artery revascularization (TCAR).
- To compare the 1-year mortality associated with these procedures in patients experiencing postoperative stroke or MI.
Main Methods:
- Retrospective analysis of a large cohort (n=202,933) from the Vascular Quality Initiative (VQI) database (2016-2023).
- Primary outcome: 1-year mortality following CEA, TFCAS, or TCAR in patients who suffered an in-hospital stroke or MI.
- Statistical analysis included Kaplan-Meier estimates and multivariable Cox regression to determine adjusted hazard ratios (aHR) for mortality, with sub-analyses based on symptomatic status.
Main Results:
- In-hospital stroke or MI significantly increased 1-year mortality risk across all procedures (aHR ranging from 3.5 to 5.9).
- Transfemoral carotid artery stenting (TFCAS) was associated with the lowest 1-year survival following stroke or MI.
- Compared to CEA, TFCAS showed a 50% higher mortality hazard (aHR=1.5), while TCAR demonstrated a 30% reduction in mortality hazard (aHR=0.7) among patients with stroke or MI.
Conclusions:
- In-hospital stroke and MI substantially elevate 1-year mortality risk after carotid revascularization.
- Transcarotid artery revascularization (TCAR) and carotid endarterectomy (CEA) demonstrated comparable 1-year survival rates in patients experiencing stroke or MI.
- Transfemoral carotid artery stenting (TFCAS) is associated with significantly higher mortality compared to CEA and TCAR following these adverse events, underscoring the importance of technique selection.
Background:
Postoperative stroke and myocardial infarction (MI) are associated with devastating postoperative morbidity and mortality, therefore limiting the protective effect of carotid revascularization procedures. Moreover, there seems to be a relationship between the severity of stroke and the type of carotid revascularization technique. We aim to investigate the impact of in-hospital stroke or MI on 1-year survival following carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), and transcarotid artery revascularization (TCAR).
Methods:
This is a retrospective analysis of patients undergoing CEA, TFCAS, and TCAR in the vascular quality initiative (VQI) database (2016-2023). Our primary outcome was 1-year mortality in patients who developed in-hospital stroke or MI following carotid revascularization. Kaplan-Meier survival estimate and multivariable Cox regression analysis were applied to calculate hazard ratios (HRs) after adjusting for potential confounders. Additionally, we conducted sub-analyses based on patients' symptomatic status.
Results:
Our study included 125,513 (61.8%) CEA, 25,875 (12.8%) TFCAS, and 51,545 (25.4%) TCAR patients. Compared to patients who did not have a postoperative stroke, the hazard of 1-year mortality was higher for those who did have a stroke following CEA (adjusted hazards ratio [aHR] = 5.9[95% confidence interval (CI):5.1-6.8] P < 0.001), TFCAS (aHR = 4.2[95% CI: 3.7-5.3] P < 0.001), and TCAR (aHR = 5.2[95% CI: 4.1-6.5] P < 0.001). The hazards of 1-year mortality after in-hospital MI were also higher following CEA (aHR = 3.8[95% CI: 3.1-4.6] P < 0.001), TFCAS (aHR = 3.5[95% CI: 2.3-5.5] P < 0.001), and TCAR (aHR = 5.1[95% CI: 3.6-7.2] P < 0.001). This trend persisted in sub-analysis based on symptomatic status. At 1 year, TFCAS showed the lowest survival following an in-hospital stroke or MI. There was no significant difference in 1-year mortality among patients who developed in-hospital stroke between TCAR and CEA (aHR = 0.93[95% CI: 0.73-1.2] P = 0.55). On the other hand, TFCAS was associated with a 50% higher mortality hazard than CEA (aHR = 1.5[95% CI: 1.1-2.1] P = 0.003), and TCAR was associated with a 30% reduction in 1-year mortality compared to TFCAS (aHR = 0.7[95% CI: 0.55-0.94] P = 0.015) among patients who developed in-hospital stroke.
Conclusion:
This large multicenter study reveals critical insights into the impact of in-hospital major adverse events on 1-year survival following carotid revascularization. The analysis indicates a significant increase in the hazard of 1-year mortality following in-hospital stroke and MI. In patients who developed in-hospital stroke or MI, there was no significant difference in 1-year survival between TCAR and CEA. On the contrary, among patients who developed in-hospital stroke or MI, TFCAS was associated with significantly higher mortality compared to CEA and TCAR. This study highlights the importance of selecting the appropriate revascularization method for each patient to improve 1-year survival.
